Research, for example, as to what point along the chain of supply really accounts for diversion of drugs from licit to illicit channels. I think this kind of thing certainly should be done and should be encouraged in Justice. But major responsibility for both research and education we feel and I feel should lie in Health, Education, and Welfare. Mr. ROGERS. Should the Attorney General have the right and authority to tell manufacturers how much they must produce or may produce of all of these classifications of drugs and how does he come to that determination would you think? Dr. BRILL. We have not attempted to evaluate this question and I would be in a difficult position to answer effectively. Mr. ROGERS. Don't you think HEW would be in a better position with their contact with physicians, with the medical community, with the scientific community, with here the reports they get from those hospitals, with the close association they have, wouldn't they be in a better position to determine what the needs are and if quotas are to be set to set such quotas rather than have the enforcement officer set such quotas? Dr. BRILL. Actually, Health, Education, and Welfare now has extensive information on prescribing and medical practices and the use of these medications. These would seem to offer the best basis for such determinations at the present time. Mr. ROGERS. I would think so because it is my understanding that the Justice Department has only $1 million that it uses for research in this area. One doctor, as has been pointed out by Dr. Carter, who is an internist, they are going to try to hire another one but they have not yet. They have three pharmacologists, I think a sociologist and maybe a psychologist, and that is their medical department. And this is to determine quotas and research. It is a very frightening prospect. I am delighted to see that the medical profession of this country is coming forth with a very clear statement to aid this committee in its deliberations. Thank you. Thank you, Mr. Chairman. Dr. BRILL. Thank you, sir. Mr. JARMAN. Mr. Nelsen. Mr. NELSEN. Thank you, Mr. Chairman. Doctor, how serious do you consider the drug addiction to be in the Nation today? Dr. BRILL. Drug addiction and drug abuse is of epidemic proportions, and, in our opinion, is a very serious matter. Mr. NELSEN. I attended a briefing at the White House at the time Art Linkletter appeared. Mr. Ingersol of the Narcotics Division was there, and he pointed out some of the problems they were faced with. Concerning enforcement, I notice that you indicated some concern about the no-knock provision. Presently we are working on a crime bill in the District of Columbia Committee. In that bill there are many safeguards built into the no-knock provision. What enforcement agencies have been up against is that many times when there is absolute evidence of the presence of narcotics, they will go into a place only to find that the evidence has been flushed down the toilet, or otherwise disposed of. The no-knock provision is an attempt to try to get the evidence that would be destroyed if officials do not have fast entry. I realize this is a very risky constitutional question involved, but I am sure you will argue that if the drug addiction has reached epidemic proportions, certainly we have to do everything we can in the area of trying to get to those who are disposing of them and pushing drugs to the public. Would you agree? Dr. BRILL. Yes, sir; I would agree. But one should make a sharp distinction between the term "drug addiction," which implies heroin mostly, and drug dependence, generally which could include the minor tranquilizers, chloral hydrate, and other substance of this type. As I understand it, the no-knock provision includes all these controlled substances if there is an offense that is possibly punishable by more than 1 year. I think that this bill attempts to deal with several classes of problems that really don't belong together very closely. Mr. NELSEN. I understand. Now I am sure you will feel when you get to the hard narcotics that drastic measures are necessary to try to curb the traffic that has been going on and is reaching huge proportions. I would agree with you that this may be a matter of semantics as to how you write the language. Now I also would agree with my colleague concerning research. It has always been my feeling that the extensive research in the drug field would be done by HEW and that the Justice Department would proceed, based on evidence from HEW. I noted in your statement you indicated that you would go along with a limited amount of research in connection with enforcement by the Justice Department, but the main emphasis on research should be in HEW. Is that right? Dr. BRILL. Exactly. Mr. NELSEN. I don't know on what basis the Justice Department feels they should proceed, how extensive their research activities would be, but I presume there is a requirement for limited research in connection with enforcement, but I think a happy medium in the language in this bill will spell that out, or guidelines could be provided in our report. Thank you for your very expert testimony. Dr. BRILL. Thank you, sir. If I may just add one sentence to my previous answer on the noknock provision. You see, by extending this no-knock provision to include so many other drugs the possibility for entrance into a physician's office is increased and the question of confidentiality of patient records is so much greater. If it were confined to hard narcotics the matter would be far more restrictive. Mr. NELSEN. I am sure you would feel as I do that we certainly want to do everything in the direction of better enforcement. At the same time perhaps we need to revise the language that is in the bill to make it clearer just what our objectives are. I would not want to leave the impression here that we are against enforcement. We are fundamentally concerned with protection of the general public in the area of narcotics and addiction. Dr. BRILL. Our association is strongly in support of that position as you stated it. We certainly feel that adequate enforcement and control is necessary for the protection of the public health. Mr. NELSEN. Thank you. Mr. JARMAN. Mr. Satterfield. Mr. CARTER. Thank you, Mr. Chairman. According to what you have stated I believe the determination of scheduling of drugs will under this bill be left to the Department of Justice. Is that correct? Dr. BRILL. The Attorney General has the final decision on that point I believe. Mr. CARTER. However, you think that this judgment should be left to HEW, is that not right? Dr. BRILL. Yes, sir. Mr. CARTER. Will physicians be required to obtain additional licenses or registrations yearly for the prescription of tranquilizers and Dr. BRILL. It is so stated in the bill that the registration has to be renewed annually even though it is also stated that such registration is contingent on and a reflection of local practices. But apparently some procedure will have to be initiated each year. Mr. CARTER. Ábout what percentage of the prescriptions a physician writes each day is for tranquilizers? Could you give an estimate? Dr. BRILL. I would like to give you that more officially in a letter but the figure of 12 percent comes to my mind in replying to your question. (The following letter and attachment was received for the record:) AMERICAN MEDICAL ASSOCIATION, LEGISLATIVE DEPARTMENT, Chicago, Ill., April 2, 1970. Mr. ED WILLIAMSON, Clerk, House Interstate and Foreign Commerce Committee, Rayburn House Office Building, Washington, D.C. DEAR MR. WILLIAMSON: I am submitting an article for the Committee's use and for the record, relating to the testimony of Dr. Henry Brill on February 17 on drug abuse legislation. On page 273 of the transcript of that testimony, Dr. Carter asked what percentage of the prescriptions a physicians writes each day is for tranquilizers. Dr. Brill estimated the figure at 12% but asked that he could submit additional information on this point. He has asked that this article, entitled "The Nature and Extent of Psychotropic Drug Usage in the United States" be incorporated in the record as a more complete response to Dr. Carter's question. Sincerely yours, ROY S. BREDDER, Legislative Attorney. Enclosure. THE NATURE AND EXTENT OF PSYCHOTROPIC DRUG by Mitchell B. Balter, Ph.D. and Jerome Levine, M.D. This report was prepared by the authors from data derived from an ongoing collaborative program that is being carried out by the Special Studies Section of the Psychopharmacology Research Branch, National Institute of Mental Health under the direction of Mitchell B. Balter, Ph. D. It was presented before the Subcommittee on Monopoly of the Select Committee on Small Business, U.S. Senate, on July 16, 1969, by Jerome Levine, M.D., Chief of the Branch. A proper understanding of the drug prescribing process requires an intimate knowledge of the patient being treated including such things as age, diagnoses, previous medical history, prior exposure to psychotropic drugs, and the circumstances which brought the patient into treatment. It is also important to know how long patients are maintained on drugs, how frequently they return to the physician, what other drugs may have been prescribed by this or some other physician, and so on. Detailed longitudinal data on patients and physicians is difficult to obtain and seldom, if ever, available on a national basis. More commonly available are data on physicians' prescribing behavior which cover a limited time period and provide only limited information on the patient, usually no more than age, sex, and current diagnosis. In those instances where longitudinal data on prescribing behavior are available, it is seldom possible to follow individual patients over time. Thus, most data currently available on prescribing behavior must be interpreted with caution. The Nature of Psychiatric Illness Before proceeding to a discussion of the extent of drug use in the treatment of psychiatric disorders, it is important to point out that the etiology of the major psychiatric disorders is essentially unknown. Psychiatric disorders therefore are descriptive con. stellations of psychological symptoms or psychopathology shown by an individual. In some cases the psychopathology may be observable by others in the behavior of the individual, but in other cases it is only by the patient's description of his subjective experience that the disorder is detected. For example, in some patients with depression we may observe that the individual's movements and thinking are slowed. There may be a loss of appetite evidenced by lack of eating and an inability to have normal sleep, characterized by early morning awakening. If the patient is asked, it is likely that subjectively he will report feeling blue and unhappy, a loss of energy and interest in his surroundings, feelings of guilt, and perhaps even a desire to be dead. The point to be made is that the diagnosis of mental disorders is difficult because the etiology is unknown, no objective laboratory tests exists, and heavy reliance is placed on the subjective report of the patient. Treatment therefore is directed for the most part at relief of subjective symptomatology and the guidelines for when medication should or should not be used are not as clear and definite as, for example, indications for the use of antibiotics, diuretics, or antihypertensive agents. Psychotherapeutic agents act by unknown mechanisms to reduce the level of symptomatology of patients but do not, to our knowledge, directly affect the causative agent of the illness in the same manner as antibiotic agents attack the microbes which cause infectious diseases. Classification of Psychotropic Agents For purposes of orientation to our presentation, I would like to present a classification of psychotropic drugs which is based primarily on clinical use of these agents and secondarily on their chemical structure. Other classifications based on pharmacological action or other parameters are possible and perhaps more comprehensive but we have selected this simpler, operationally defined classificaton as best serving present needs. Psychotropic agents are defined as those substances which have their main or principal effect on mood, thought processes, or behavior. The first chart shows six classes of psychotropic agents; namely, major tranquilizers, minor tranquilizers, antidepressant agents, stimulants, sedatives, and hypnotics. The major tranquilizers of which the pheno thiazine-related compounds compose the bulk of the class were introduced into widespread use in the mid-1950's. They are primarily thought of as agents useful in the treatment of the major or most severe psychiatric disorders; namely the psychoses. This class of drugs is therefore also known as antipsychotic agents. Their use in schizophrenic patients leads to a decrease in agitation, thought disorder, hallucinations, and delusions. The most common side effects include drowsiness (usually transient in nature), extrapyramidal symp toms such as are seen in Parkinson's disease, and orthostatic hypotension. Drug dependence of a psychological or physiological type leading to addiction does not occur. Rather rare toxic effects of agranu. locytosis and hepatocellular liver damage occur and prolonged chronic use in high dosage has led to increased skin pigmentation and eye opacities which fortunately do not usually result in impaired vision. The minor tranquilizers, also referred to as antianxiety agents, became available in the early and mid1950's. These drugs are thought to represent an advance in the treatment of disorders which have a large anxiety component because they alleviate anxiety |